Provider Demographics
NPI:1316201619
Name:TIETJEN, STEPHEN RAY (DC)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:RAY
Last Name:TIETJEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5636 HAVANA DR.
Mailing Address - Street 2:
Mailing Address - City:NORTH RICHLAND HILLS
Mailing Address - State:TX
Mailing Address - Zip Code:76180
Mailing Address - Country:US
Mailing Address - Phone:817-991-6428
Mailing Address - Fax:
Practice Address - Street 1:5636 HAVANA DR
Practice Address - Street 2:
Practice Address - City:NORTH RICHLAND HILLS
Practice Address - State:TX
Practice Address - Zip Code:76180-6558
Practice Address - Country:US
Practice Address - Phone:817-991-6428
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-02
Last Update Date:2012-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12018111N00000X, 111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation
No111N00000XChiropractic ProvidersChiropractor